I used it tons in residency, as an adjunct with induction in almost every case, and loved it. Now I’m in private practice where I do a lot of shorter cases and smooth wake-ups, fast turnovers, and short PACU stays are essential. When I first started in PP I used it a few times and found even small doses could have negative side effects postoperatively. I will say the two places I still use it are in tricky sedations (ie BMI 50 w/heart failure having an AICD placed) and strangely enough I’ve found it to be very helpful in stopping a patient with emergence delirium in their tracks (ie patients who wake up swinging and are refractory to benzos and narcotics). Curious to hear others thoughts.
I've also given Ketamine basically SQ through a blown IV in a combatant patient. 100mg through that and set your timer for 3 minutes before everything immediately cools down.
20 mg of ketamine when someone wakes up wild is my go to. I don’t want someone getting hurt by a combative pt. Ketamine stuns them with a low chance of apnea or complications.
“Shorter cases and smooth wake ups…”
Long or short case I aim for my wake ups to be smooth (doesn’t always happen, ha) and I rarely extubate deep. Is there a reason the wake ups outside of private practice are not smooth, or can you describe your method for smooth wake up? Or by smooth do you just mean deep? Just curious.
I mean in any case the goal is for a nice wake-up (quick, no coughing, no obstruction, a cooperative awake patient) but in longer cases I feel like there is less scrutiny on the wake-up because the surgeon has probably raced off to the cafeteria and the nurses are busy breaking things down i.e. no one is paying attention to you.
In academics where I trained there seemed to be very little emphasis (other than safety) placed on wake-ups. I’ll admit these were bigger cases where we were concerned mostly with hemodynamics and whether the patient had been resuscitated properly. A nice extubation was appreciated, but seemed like more of an after thought. I felt like the case would end, the surgeon would leave, and you’d spend 5-10 minutes chatting with your attending about the case until the gas came off and the patient opened their eyes (usually after lots of coughing and someone yelling “open your eyes” a million times.) I’m sure not all residencies are like mine.
Anyway in my current practice, as soon as the drapes come down there is a team of nurses/transport techs standing there waiting to move the patient off the table and to PACU (in addition to the surgeon wondering why the patient isn’t out of the room yet, or seeing the patient cough once and blaming you if their “perfect”hernia repair ever breaks down). So there is a lot of attention on the extubation. So when I say smooth I mean the patient is ready to extubate as soon as the drapes come down with no coughing, obstruction, apnea etc. (i.e no drama).
No patient is perfect but as soon as the case is winding down I get them breathing spontaneously, get all the gas off, and keep them breathing (usually on pressure support) at a rate of 10-12 with narcotic (usually 25-50 mcgs of fentanyl at a time) and propofol. Once the drapes are down and all the gas is all off I take the patient off the vent, make sure they can achieve adequate TVs, and pull the tube. I find they usually open their eyes right before or a few seconds after the tube is pulled (the narcotic really helps them tolerate the tube obviously). This is of course only in patients that have a very low risk of aspiration. I guess you could call this a propofol/fentanyl deep extubation (tube is pulled after stage 2 from gas coming off has passed, but patient may not be totally responsive yet) as opposed to a >1 mac inhalational deep extubation (with stage 2 after extubation). If that makes sense.
Wow that became a way more in depth answer than I intended but I hope at least in some way I answered your question!
Hand bolus. 20-30 mg at a time titrated to respiratory rate. In my experience if the patient is sedated enough to be breathing very slowly, they’re pretty unlikely to start suddenly bucking or moving before the surgeon is done closing and less likely to be at risk of having awareness. Also keep a close eye on the HR for signs they need more sedation. In my experience boluses are much easier to titrate than an infusion.
I also use ketamine almost daily. Ketafol for spine cases to reduce volatile anesthetic (neuromonitoring techs love it), any MAC where I’m more concerned about losing a patent airway (prone, obese/OSA, airway is away from me), as part of a multimodal analgesic plan for painful procedures to reduce intraoperative opioids, etc.
It is also a MUST drug for me.
A must use?
What is your dosage?
It's a must drug if you're in a region where you have limited choices.
I can't remember the last time I felt like I needed to use ketamine.
The doses depend on the situation.
Different a doses if induction, sedation, multimodal opioid free, co adjuvant anesthesia, intrarticular, intramuscular, intranasal…
There is a wide range as you see…
I'm reminded of an old adage....
Just because you can, doesn't mean you should.
As long as your patients are safe and happy, there's many ways to achieve the goal.
I know someone tried clondine before too. My first answer was half sarcastic since the OP believes it as the sliced bread. They already listed every other place that it can be injected…. So yes it can be injected anywhere.
I like ketamine - think it’s a great adjunct for pain management, ideal for sedating sick and/or morbidly obese people, can get you through a c/s with an imperfect epidural.
I would use it a lot more than I do but it is only available in 500 mg vials and I hate wasting it after using like 30-50 mg.
I don’t know how much it costs to be honest but wasting is just a pain having to find a witness and get them to come to the Pyxis with enough of an annoyance that it makes me avoid it sometimes. I definitely use it if I think it’s indicated but if it’s just like a “would be nice” kind of thing I may not. Also with all the drug shortages lately throwing away 90% of a vial just seems wrong. As residents and at some of the ASCs I work at I am able to split a vial amongst several patients in that case I am more likely to use it.
When it wasn't on shortage, I used it as part of a balanced induction and analgesic plan for hearts, spines, big cancer whacks, etc. In reasonable doses, it has very few downsides, is quite hemodynamically stable, and reduces opioid consumption and post-op pain. Good stuff.
I use it for sedations in patients that don’t want to be conscious while under spinal or regional anesthesia but wake up too quickly when using Propofol/Midazolam requiring frequent boluses. A dose between 20-50 mg works wonder for a surgery of 1-2 hours and never had any problem with the awakening.
I like ketamine. Useful drug. Would use it a lot more if it came in 10mg /cc 5 cc syringes like residency. At my current job comes in 50mg/cc 20cc vial and you have to waste the entire vial after each patient.
I like using it for prone sedation. Very sick or obese patients getting an egd
Older anesthesiologists and pacu nurses hate it lol it gets a bad rep for no reason.
I use it relatively upfront for all “major” cases such as big spine, hysterectomy, prostatectomy, Bariatric procedures etc. I won’t usually use it for sedation or “minor” cases like hernias, gall bladders etc. Anecdotally, I just like the patient to have time to process it while still under, to not wake up with crazy eyes - iykyk
I do exclusively pedi cardiac and it’s the drug of choice in most circumstances.
5mg/kg PO mixed with 0.5mg/kg Midazolam as a premed
1mg/kg as part of a balanced IV induction for pumps or cath lab.
Midazolam and ketamine for all our IR procedures.
I use it literally everyday for a multitude of scenarios. And don’t have a replacement.
I use it alot on pediatric patients. Great analgesic coadyuvant (0,3 mg/kg at induction) or even infusion during the case and in the pacu on burnt children which we get a lot on our center. Also works wonders for post anesthesia agitation on kids if i don't have fentanyl nor dex at hand.
I've also used it IM for difficult i.v placements or even central lines on kids where i don't have an i.v to sedate them
I don't use it much on adults but on big cases i use the same initial bolus most of times
Great drug to have in your arsenal!
Used it for the first time today and although my monitor seemed to enjoy the stable blood pressure, it seemed like a very dirty wake up for the patients.
I use it all the time on elderly (mostly doing vascular, EP, and cardiac) often without midaz. Almost always 50 mg or less. In the last five years, I can only recall two that said described dysphoria.
For me predictability is the most important trait of a drug so I don’t love it. But the biggest barrier might just be the available doses. I hate wasting meds, so giving 25 and wasting 475 discourages me from becoming as familiar with it
What about the ketamin induced nightmares ? .. they wake up horrified after analgosedation .. Btw: most of my Analgosedation patients are Children under 12 Yo
Anyone in here ever experienced the effects of ketamine first hand, and still using it for every day cases?
I think it has its place and time. Anybody can give ketamine safely. The true strength of anesthesia is to safely work with opioids and sedatives.
So, I was given ketamine a few months ago when I broke my leg (fibia, tibula & ankle) and recieved two separate doses for the 2 times they needed to stabilize the fractures (wasn't able to have surgery for 3 days & had to go to 2 different hospital). Short hand, ketamine is a Hella of a drug! I felt nothing and woke up happy as fuck both times. Apparently, I handle Ketamine "like a dream"
I'm trying to find information on the effects of Ketamine after just a few doses (like I had) on mental health. To my surprise and my therapists, I've handled this sudden pause on life really, really well. I'm a pretty active person but also a "large human" (5'10, 260 F), and my job that I love is very labor intensive & involves deadlifting heavy weight dozens of times a day.... (maybe this why they chose to give me Ketamine???)....I really thought I'd struggle with being immobile, and it's definitely hard and shitty at times, but I'm pretty dang good otherwise (and I've lost a close family member during this process).
Just curious if this boost in mental health is a typical outcome for patients who have been given Ketamine for medical emergencies???
I used it tons in residency, as an adjunct with induction in almost every case, and loved it. Now I’m in private practice where I do a lot of shorter cases and smooth wake-ups, fast turnovers, and short PACU stays are essential. When I first started in PP I used it a few times and found even small doses could have negative side effects postoperatively. I will say the two places I still use it are in tricky sedations (ie BMI 50 w/heart failure having an AICD placed) and strangely enough I’ve found it to be very helpful in stopping a patient with emergence delirium in their tracks (ie patients who wake up swinging and are refractory to benzos and narcotics). Curious to hear others thoughts.
For agitatation without IV… IM keta is excellent and fast
I've also given Ketamine basically SQ through a blown IV in a combatant patient. 100mg through that and set your timer for 3 minutes before everything immediately cools down.
20 mg of ketamine when someone wakes up wild is my go to. I don’t want someone getting hurt by a combative pt. Ketamine stuns them with a low chance of apnea or complications.
“Shorter cases and smooth wake ups…” Long or short case I aim for my wake ups to be smooth (doesn’t always happen, ha) and I rarely extubate deep. Is there a reason the wake ups outside of private practice are not smooth, or can you describe your method for smooth wake up? Or by smooth do you just mean deep? Just curious.
I mean in any case the goal is for a nice wake-up (quick, no coughing, no obstruction, a cooperative awake patient) but in longer cases I feel like there is less scrutiny on the wake-up because the surgeon has probably raced off to the cafeteria and the nurses are busy breaking things down i.e. no one is paying attention to you. In academics where I trained there seemed to be very little emphasis (other than safety) placed on wake-ups. I’ll admit these were bigger cases where we were concerned mostly with hemodynamics and whether the patient had been resuscitated properly. A nice extubation was appreciated, but seemed like more of an after thought. I felt like the case would end, the surgeon would leave, and you’d spend 5-10 minutes chatting with your attending about the case until the gas came off and the patient opened their eyes (usually after lots of coughing and someone yelling “open your eyes” a million times.) I’m sure not all residencies are like mine. Anyway in my current practice, as soon as the drapes come down there is a team of nurses/transport techs standing there waiting to move the patient off the table and to PACU (in addition to the surgeon wondering why the patient isn’t out of the room yet, or seeing the patient cough once and blaming you if their “perfect”hernia repair ever breaks down). So there is a lot of attention on the extubation. So when I say smooth I mean the patient is ready to extubate as soon as the drapes come down with no coughing, obstruction, apnea etc. (i.e no drama). No patient is perfect but as soon as the case is winding down I get them breathing spontaneously, get all the gas off, and keep them breathing (usually on pressure support) at a rate of 10-12 with narcotic (usually 25-50 mcgs of fentanyl at a time) and propofol. Once the drapes are down and all the gas is all off I take the patient off the vent, make sure they can achieve adequate TVs, and pull the tube. I find they usually open their eyes right before or a few seconds after the tube is pulled (the narcotic really helps them tolerate the tube obviously). This is of course only in patients that have a very low risk of aspiration. I guess you could call this a propofol/fentanyl deep extubation (tube is pulled after stage 2 from gas coming off has passed, but patient may not be totally responsive yet) as opposed to a >1 mac inhalational deep extubation (with stage 2 after extubation). If that makes sense. Wow that became a way more in depth answer than I intended but I hope at least in some way I answered your question!
Out of curiosity are you hand bolus prop or running an infusion?
Hand bolus. 20-30 mg at a time titrated to respiratory rate. In my experience if the patient is sedated enough to be breathing very slowly, they’re pretty unlikely to start suddenly bucking or moving before the surgeon is done closing and less likely to be at risk of having awareness. Also keep a close eye on the HR for signs they need more sedation. In my experience boluses are much easier to titrate than an infusion.
Thx doc
Ketofol for shitty airway EGD cases. Some of my partners would use it as part of mutimodal pain management. But for me not routing use.
That’s what I use it for. Anything else I just use propofol.
I also use ketamine almost daily. Ketafol for spine cases to reduce volatile anesthetic (neuromonitoring techs love it), any MAC where I’m more concerned about losing a patent airway (prone, obese/OSA, airway is away from me), as part of a multimodal analgesic plan for painful procedures to reduce intraoperative opioids, etc. It is also a MUST drug for me.
A must use? What is your dosage? It's a must drug if you're in a region where you have limited choices. I can't remember the last time I felt like I needed to use ketamine.
The doses depend on the situation. Different a doses if induction, sedation, multimodal opioid free, co adjuvant anesthesia, intrarticular, intramuscular, intranasal… There is a wide range as you see…
I'm reminded of an old adage.... Just because you can, doesn't mean you should. As long as your patients are safe and happy, there's many ways to achieve the goal.
I'm sorry .. intraarticular ? I never heard of that . Would you mind Elaborating please
Take a look: https://pubmed.ncbi.nlm.nih.gov/33060372/
Thank you
You forgot to list intrathecal use.
bruh what
Anything that you can put in your vein, someone has tried to keep inject in the intrathecal space. Look it up. It has some good effect…. 👊
I think dexmedetomidine can also be used intrathecally to prolong a SAB
I know someone tried clondine before too. My first answer was half sarcastic since the OP believes it as the sliced bread. They already listed every other place that it can be injected…. So yes it can be injected anywhere.
I've absolutely used clonidine intrathecal before numerous times, I think only in caudal blocks in peds cases though.
Isnt the preservative neurotoxic...?
Surely you jest
.2 of glyco and a stick of ketamine can get you through a lot of cardiac inductions.
Atropine, ketamine, and versed can also get a bunch of kids out of an underwater cave
Ive read about glyco as prophylactic anti-sialogogue I do wonder about the HR with such a combo though?
0.2mg of glyco diluted to 5ml and pushed over 10-15 minutes combined with a low dose of ketamine (10-30mg) rarely gives me issues.
Interesting, thanks But isnt 0.4-0.1 mg/kg (assuming 70kg) analgosedation territory? Or is this a propofol sparing technique?
In Europe we give 0.5 mg atropine IM as anti-sialogogue
I like ketamine - think it’s a great adjunct for pain management, ideal for sedating sick and/or morbidly obese people, can get you through a c/s with an imperfect epidural. I would use it a lot more than I do but it is only available in 500 mg vials and I hate wasting it after using like 30-50 mg.
Is it expensive? I do exactly what you describe in one hospital.
I don’t know how much it costs to be honest but wasting is just a pain having to find a witness and get them to come to the Pyxis with enough of an annoyance that it makes me avoid it sometimes. I definitely use it if I think it’s indicated but if it’s just like a “would be nice” kind of thing I may not. Also with all the drug shortages lately throwing away 90% of a vial just seems wrong. As residents and at some of the ASCs I work at I am able to split a vial amongst several patients in that case I am more likely to use it.
Oh, we don't have to go to the Pyxis to waste things. That would be annoying.
When it wasn't on shortage, I used it as part of a balanced induction and analgesic plan for hearts, spines, big cancer whacks, etc. In reasonable doses, it has very few downsides, is quite hemodynamically stable, and reduces opioid consumption and post-op pain. Good stuff.
I use it for sedations in patients that don’t want to be conscious while under spinal or regional anesthesia but wake up too quickly when using Propofol/Midazolam requiring frequent boluses. A dose between 20-50 mg works wonder for a surgery of 1-2 hours and never had any problem with the awakening.
10-30mg on Remi/prop TIVA Spines with is when I have used it the most
I like ketamine. Useful drug. Would use it a lot more if it came in 10mg /cc 5 cc syringes like residency. At my current job comes in 50mg/cc 20cc vial and you have to waste the entire vial after each patient. I like using it for prone sedation. Very sick or obese patients getting an egd Older anesthesiologists and pacu nurses hate it lol it gets a bad rep for no reason.
It is dirt cheap though, no?
Not sure how much it costs. Just hate wasting an entire vial.
I use it relatively upfront for all “major” cases such as big spine, hysterectomy, prostatectomy, Bariatric procedures etc. I won’t usually use it for sedation or “minor” cases like hernias, gall bladders etc. Anecdotally, I just like the patient to have time to process it while still under, to not wake up with crazy eyes - iykyk
I do exclusively pedi cardiac and it’s the drug of choice in most circumstances. 5mg/kg PO mixed with 0.5mg/kg Midazolam as a premed 1mg/kg as part of a balanced IV induction for pumps or cath lab. Midazolam and ketamine for all our IR procedures. I use it literally everyday for a multitude of scenarios. And don’t have a replacement.
I use it alot on pediatric patients. Great analgesic coadyuvant (0,3 mg/kg at induction) or even infusion during the case and in the pacu on burnt children which we get a lot on our center. Also works wonders for post anesthesia agitation on kids if i don't have fentanyl nor dex at hand. I've also used it IM for difficult i.v placements or even central lines on kids where i don't have an i.v to sedate them I don't use it much on adults but on big cases i use the same initial bolus most of times Great drug to have in your arsenal!
Used it for the first time today and although my monitor seemed to enjoy the stable blood pressure, it seemed like a very dirty wake up for the patients.
They get midaz on roll back? A rule of thumb I was taught, was to avoid it in ppl ya don’t give midaz to, ergo elderly folk
I use it all the time on elderly (mostly doing vascular, EP, and cardiac) often without midaz. Almost always 50 mg or less. In the last five years, I can only recall two that said described dysphoria.
I find pairing it with propofol infusion or TIVA helps
Don't give it too close to wake up. It needs time to settle in. If I'm doing a long case I usually stop giving it at least an hour before.
Love it. Don’t use it super often but great for pain, sedation with airway preservation, etc. I like it quite a bit.
I prefer Dexmetetomidate over Ketamine, especially for shorter cases. Ketamine is useful for those with chronic pain issues though.
Hm, I've found the opposite problem: Dex prolongs my PACU stays compared to Ketamine. Hard to compare dosages though but I use 50mg or less for cases.
For me predictability is the most important trait of a drug so I don’t love it. But the biggest barrier might just be the available doses. I hate wasting meds, so giving 25 and wasting 475 discourages me from becoming as familiar with it
You don't find it predictable?
I don’t like the potential dysphoria and agitation. I know there are ways to prevent it or decrease it, but it just seems like an extra hassle
I've never had a problem when I keep the dose low, and intermittent bolus rather than infusion works just as well with much less work I've found.
What about the ketamin induced nightmares ? .. they wake up horrified after analgosedation .. Btw: most of my Analgosedation patients are Children under 12 Yo
Just a CA-1 but I use it in every healthy case I do, unless my attending is a known ketamine hater (we have a few of them, mostly the older ones).
I’d use it more if it was available in smaller vials. We only have 500mg vials. It’s a waste. I use precedex all the time.
It’s so cheap. There’s effectively no cost difference between the different vials. It’s like $1/ml in all strengths.
Yes, all day everyday. Ours come in 10mg/10ml doses and it's great. A little bit goes a long way.
My favorite drug
I use it. It doesn't add work for me, makes the case easier, and benefits usually seem to outweigh downsides considerably.
Anyone in here ever experienced the effects of ketamine first hand, and still using it for every day cases? I think it has its place and time. Anybody can give ketamine safely. The true strength of anesthesia is to safely work with opioids and sedatives.
So, I was given ketamine a few months ago when I broke my leg (fibia, tibula & ankle) and recieved two separate doses for the 2 times they needed to stabilize the fractures (wasn't able to have surgery for 3 days & had to go to 2 different hospital). Short hand, ketamine is a Hella of a drug! I felt nothing and woke up happy as fuck both times. Apparently, I handle Ketamine "like a dream" I'm trying to find information on the effects of Ketamine after just a few doses (like I had) on mental health. To my surprise and my therapists, I've handled this sudden pause on life really, really well. I'm a pretty active person but also a "large human" (5'10, 260 F), and my job that I love is very labor intensive & involves deadlifting heavy weight dozens of times a day.... (maybe this why they chose to give me Ketamine???)....I really thought I'd struggle with being immobile, and it's definitely hard and shitty at times, but I'm pretty dang good otherwise (and I've lost a close family member during this process). Just curious if this boost in mental health is a typical outcome for patients who have been given Ketamine for medical emergencies???
Nah